Many cases of so-called irritable bladder and chronic cystitis are caused primarily by laceration of the perineum, which produces cystocele or prolapse of the posterior wall of the bladder; and such cases can be cured only by curing the cystocele. A cystocele varies much in size. Every long-standing case of laceration of the perineum in the sulci presents a certain degree of prolapse of the anterior vaginal wall. The tumor may remain within the vagina and be rendered prominent only upon efforts at straining, or it may protrude through the vulva as a mass the size of a duck’s egg. As a cystocele is caused by laceration of the perineum, it can be cured only by repair of this laceration. The most important part of the treatment, therefore, is perineorrhaphy, which should always be performed. Usually this operation is sufficient. If the anterior wall of the vagina is supported, the tissues will recover their tonicity and contract, and the tumor will disappear. In some cases, however, where the mucous membrane of the anterior vaginal wall has become much stretched and redundant in the normal-sized vagina, it is advisable, in addition to the perineorrhaphy, to perform a plastic operation on the anterior wall in order to diminish the area of the vaginal mucous membrane. Such an operation is called anterior colporrhaphy. A variety of operations of this kind have been invented. The various forms are modified according to the requirements of the case and the whims of the operator. In one form of operation an oval area is denuded (Fig. 58), and the edges are brought together by interrupted sutures passed beneath the whole denuded surface. [Illustration: FIG. 58.--Oval denudation for cystocele: sutures introduced.] [Illustration: FIG. 59.--Sims’ operation for cystocele.] As the transverse measurement of the vagina is greater in the upper than in the lower part, an operation by which a greater amount of the excess of tissue is taken in above than below is often desirable. Such an operation is represented in Fig. 59. Two strips, about one-third to one-half inch in breadth, are denuded on each side of the anterior wall, extending from the position of the internal urinary meatus upward toward the lateral vaginal fornices. The length of these strips varies with the case, and depends upon the size of the upper portion of the vagina. It is often desirable to carry the denudation to the level of the external os. The denuded surfaces are brought into apposition by interrupted sutures. By this operation the whole caliber of the vagina is narrowed from above downward. The degree of divergence of the denuded strips may be determined by seizing portions of tissue with tenacula upon each side and bringing them together, thus determining the amount of tension which will be put upon the sutures. [Illustration: FIG. 60.--Dudley’s operation for cystocele (Ashton, modified from Dudley).]